Vermont Center for Dental Implants & Maxillofacial Surgery

Cosmetic Injectables 101 – Botox vs Fillers

 

For many patients common questions about injectables involve their uses and longevity. Injectables can be divided into 2 categories: Neuromodulators and Dermal Fillers.

 1) Neuromodulators  – With names like Botox, Dysport, or Xeomin, these medications are neuromodulators and act by relaxing muscles that cause facial expressions such as frowning or squinting which over time lead to wrinkles.  The effects of  neuromodulators last for 3 to 4 months and wear off gradually.    For this reason Botox and other neuromodulators have  high safety profiles and low complication rates when used by trained professionals. The specific areas in the face that are most commonly treated with Neuromodulators are; the nasal furrow between the eyes, the horizontal lines of the forehead, and the crows feet. All of these lines are caused by muscle contraction which over a long period of time will cause lines in the skin to form. By  relaxing muscle contraction,  these lines slowly disappear if they are not too deep and this is why it’s best to start the use of these muscle relaxants as the lines 1st appear.  The rules of three’s best explains how these agents work over time.  Patients will first notice the effect of neuromodulators in 3 days,  the maximal effect takes 3 weeks to develop, and the effect last 3 months before it starts to wear off. If a patient stops using a neuromodulator the lines caused by facial expression return slowly but no worse then before treatment.  To keep the full effect of these agents most patients receive treatments three to four times per year. Other uses of neuromodulators include treatment of migraines, TMJ pain, and excessive sweating of hands and underarms.  Complications are rare with the most common being asymmetry in the eyebrow which can easily be corrected.                                                                                                                                                                             

 2) Dermal  Fillers  – As we age we lose the natural substance hyaluronic acid in our skin which acts to absorb water and give skin a full, firm, and  smooth appearance.  Loss of hyaluronic acid leads to loss of fullness of cheeks, lips and deepening of facial lines. With a number of trade names such as Restylane, Perlane, and Radiesse, most fillers contain hyaluronic acid and come as gels that can be injected superficially under the skin to plump up lips and reduce fine lines or more deeply to reduce the appearance of deep folds around the mouth, nose, and cheeks. Additionally, fillers can be used to plump up broad areas such as the cheek, commonly referred to as the” liquid lift”  and are effective in restoring lost volume in the cheek area and reducing the depth of nasolabial lines. Generally,  fillers will last approximately 6 to 12  months unless one is using a permanent filler. Most fillers are designed for specific areas ie. fine or small particle fillers are used on the lips to reduce the apearance of fine lines while larger particle fillers are used more deeply to reduce the appearance of larger folds around the mouth and nose.

 

 

 

Advanced Bone Grafting – Widening The Narrow Alveolar Ridge

 

The most common challenge in placing dental implants is inadequate bone width at the implant site.  When teeth are lost so too is bone through disuse atrophy, infection, and/or trauma. If a critical amount of bone is lost then the  jaw bone needs to be built up or grafted to allow implant placement.  There are many approaches used to widen the narrow alveolar ridge or jaw bone. Autogenous bone is obtained by harvesting bone from the patients jaw and placing it at the implant site.  Onlay grafts (which are composed of solid blocks of autogenous bone) do not compress and are one way of accomplishing ridge widening. However, donor site morbidity and the need to shape the bone make onlay grafts more time consuming and increase patient recovery time. When using a particulate graft (bone obtained from a tissue bank with the consistency of sea salt) compression and loss of volume are inevitable. Using a particulate or allograft avoids the need to harvest bone from the patient’s own jaw and reduces postoperative discomfort.  The challenge in using this type of graft to increase ridge width is maintaining the shape of the grafted area while the graft is healing. Soft tissue contracture applies pressure to the particulate graft, compacting and flattening it, reducing the final width of the grafted ridge.   One way to support the soft tissue and prevent the graft from being compressed is to use bone screws which act like tent poles to support the mucoperiosteum or  gum tissue. When the ridge is less than 4 mm wide, I often use the Tent Pole technique. Typically, the graft is placed along with the tenting screws and if adequate bone is present the dental implants may be placed at the same time. After 4 to 6 months of healing the tenting screws are removed easily with a small incision over the head of the screw.  The dental implants are then placed if this has not already been done at the time of grafting. The case below is typical and should result in a ridge that was widened from 2 mm to 6 mm. The tenting screws shown in fig.1, particulate bone graft placed over the screws fig. 2, and a collagen membrane placed over graft to aid in supporting the tissue and protect the graft from soft tissue ingrowth fig. 3.

 

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3D Implant Navigation Improves Accuracy

Just back from the Annual Oral & Maxillofacial Surgery Meeting in Washington D.C.. As always there were many interesting courses that I attended including; advances in  cosmetic surgery and injectables, sleep apnea, infections, and dental implants. I had the opportunity to try a  3D navigation system (called the X – Guide) that allows the surgeon to place implants while watching the implant drill  on a video monitor showing the patient’s jaw as seen on the Cone Beam Cat Scan. The implant is first placed virtually using traditional implant planning software . Then the X-Guide system places a dynamic focus point over the precise area where the implant will be placed.  It does this by placing fiduciary markers in the mouth and on the handpiece which allows the software using cameras mounted to an overhead light to localize the handpiece relative to the patient and the CBCT. The surgeon looks at the focus point on a monitor which guides the handpiece to place the implant to the predetermined depth, position, and angulation. This technology replaces static surgical guides and eliminates the delay in fabrication of surgical stents. It also improves implant position when implants are placed free hand. I am very interested in using the X Guide as a training tool for residents that I train at the University of Vermont Medical Center. Interestingly, this same technology has been used for years in Neurosurgery to allow surgeons to remove tumors of the brain with great precision.x guide graphic

Advances in Implant Dentistry – The Angulated Screw Channel

Until recently implant crowns in the anterior region required cementation for retention.  Now with the introduction of the Angulated Screw Channel  (ASC) abutment by Nobel Biocare it is possible to have screw retained restorations anywhere in the mouth despite implant angulation or bone morphology. Screw retained implant crowns may improve the soft tissue health around implants and facilitate the restorative process.  This approach can greatly simplify the seating of crowns and abutments by allowing the laboratory technician to place the screw access channel in an optimal position. The new Omnigrip driver can apply 35nCM torque at up to 25 degrees off axis. The driver has a pick up function allowing screws to be handled much more easily.
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